Navigating portal hypertension: Unlocking safe passage to healthy pregnancy in EHPVO.

BACKGROUND AND AIMS: Pregnancy is associated with hyperdynamic circulatory state and increased risk of portal hypertension related complications in patients with extra-hepatic portal vein obstruction (EHPVO). We aim to study the impact of EHPVO on pregnancy-related outcomes with focus on subset of patients with UGIB (upper GI bleed). METHODS: Retrospective analysis of obstetric, maternal and neonatal outcomes of patients with EHPVO registered between January 2006 and December 2022. Forty-five patients were included. Forty-five healthy females with low-risk pregnancies formed the control group. RESULTS: Adverse obstetric and neonatal outcomes were comparable between EHPVO and control group (22% vs. 28.6%; p > .05; low birth weight/ small for gestational age 17.8% vs. 36%, p = .0918 and 14.2% vs. 10%, p = .5698 respectively). Adverse outcomes were similar in patients with and without history of UGIB (26.3% vs. 19.4%, p = .0814; 17.8% vs. 36%, p = .0918; 14.2% vs. 10%, p = .5698). There was no maternal mortality in both the groups. A total of 7% pregnancies in EHPVO patients were complicated by ascites. CONCLUSIONS: EHPVO pregnancies have successful obstetric and neonatal outcomes with adequate management of portal hypertension.

Incidence & factors influencing maternal near miss events in tertiary hospitals of Maharashtra, India.

Background & objectives: Government of India (GoI) released operational guidelines for maternal near miss-review (MNM-R) in 2014 for use by programme managers of public health system to assist them for conducting MNM-R. The objective of the present study was to review the incidence and factors influencing MNM events in two tertiary hospitals of Maharashtra, India, as per the operational guidelines of the GoI released in 2014 and identify delays based on three-delay model to prevent such events in future. Methods: This prospective observational study was conducted in two tertiary hospitals of Maharashtra, from July 2018 to November 2020. All women during pregnancy, childbirth or postpartum upto 42 days meeting the eligibility criteria of MNM as per the 2014 GoI guidelines were included as cases (n=228), interviewed and discussed during the monthly MNM meetings at these hospitals. Results: The incidence of MNM was 11/1000 live births; the ratio of MNM to maternal deaths was 1.2:1. Leading causes of MNM were haemorrhage (36.4%) and hypertensive disorders of pregnancy (30.3%). Haemorrhage was maximum (70.6%) in abortion and ectopic pregnancies. Majority of the women (80.2%) were anaemic, of whom 32.4 per cent had severe anaemia. Eighty six per cent of women included in the study had MNM events at the time of admission and 81 per cent were referred from lower facilities. Level one and two delays were reported by 52.6 and 32.5 per cent of women, respectively. Level three delay at referral centres and at tertiary hospitals was reported by 69.7 and 48.2 per cent of women, respectively. Interpretation & conclusions: The findings of this study suggest that MNM-R should be undertaken at all tertiary hospitals in India as per GoI guidelines to identify gaps based on three-delay model. These hospitals should implement interventions as per the identified gaps with emphasis on strengthening the infrastructure, facilities and manpower at the first-referral units.

Vaginal microbiota of asymptomatic bacterial vaginosis and vulvovaginal candidiasis: Are they different from normal microbiota?

Vaginal microbiota contributes in maintaining and protecting the urogenital niche from infections and their sequelae. Despite extensive research, microbiome studies have often ignored asymptomatic bacterial vaginosis (BV) and vulvovaginal candidiasis (VVC). The present study aimed to explore the cultivable vaginal bacterial and mycological communities in women asymptomatic for BV and VVC using multiplex PCR and species-specific PCR. Vaginal swabs collected from 199 participants asymptomatic for urogenital infections, scored by Nugent criteria indicated 73.9% had normal microbiota, 11.6% intermediate and 14.5% BV. The most frequent Lactobacillus species in normal women were L. iners (69.4%), L. crispatus (24.5%), L. reuteri (20.4%). Women with BV colonized L. iners (62.1%); L. rhamnosus (41.4%); L. salivarius (13.7%) and L. reuteri (7.2%). Furthermore, L. crispatus was associated with normal microbiota, whereas L. iners was a frequent member of normal and dysbiotic microbiota. Lactobacillus abundance and species richness reduced in asymptomatic BV. Also L. crispatus, L. fermentum, L. acidophilus and L. delbruckii were absent in these women. L. iners significantly co-existed with other Lactobacillus species, indicating its failure in independently maintaining the healthy vaginal niche. Of 30.4% women detected with Candida, 72.1% constituted non-albicans Candida. Predominance of C. albicans increased from 18.4% in healthy to 60% in women with asymptomatic BV; whereas distribution of BV related bacteria did not vary across the groups. Heterogeneous population of lactobacilli in 80.8% of normal women calls attention towards cumulative effects of these species in safeguarding the vaginal microenvironment. Since the microbiota of asymptomatic BV was different from healthy, screening and management could be encouraged to avoid further complications of infections.

Differential proteomics of circulating extracellular vesicles of placental origin isolated from women with early-onset preeclampsia reveal aberrant innate immune and hemostasis processes.

PROBLEM: Early-onset preeclampsia (EOPE) is a severe gestational hypertensive disorder with significant feto-maternal morbidity and mortality due to uteroplacental insufficiency. Circulating extracellular vesicles of placental origin (EV-P) are known to be involved in the pathophysiology of EOPE and might serve as an ideal reservoir for its specific biomarkers. Therefore, we aimed to characterize and perform comparative proteomics of circulating EV-P from healthy pregnant and EOPE women before delivery. METHOD OF STUDY: The EV-P from both groups were isolated using immunoaffinity and were characterized using transmission electron microscopy, dynamic light scattering, nanoparticle tracking analysis, and immunoblotting. Following IgG albumin depletion, the pooled proteins that were isolated from EV-P of both groups were subjected to quantitative TMT proteomics. RESULTS: Circulating term EV-P isolated from both groups revealed ∼150 nm spherical vesicles containing CD9 and CD63 along with placental PLAP and HLA-G proteins. Additionally, the concentration of EOPE-derived EV-P was significantly increased. A total of 208 proteins were identified, with 26 among them being differentially abundant in EV-P of EOPE women. This study linked the pathophysiology of EOPE to 19 known and seven novel proteins associated with innate immune responses such as complement and TLR signaling along with hemostasis and oxygen homeostasis. CONCLUSION: The theory suggesting circulating EVs of placental origin could mimic molecular information from the parent organ-"the placenta"-is strengthened by this study. The findings pave the way for possible discovery of novel prognostic and predictive biomarkers as well as provide insight into the mechanisms driving the pathogenesis of EOPE.

How Common are Depressive-Anxiety States, Body Image Concerns and Low Self-Esteem in Patients of PCOS?

BACKGROUND: Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of reproductive age with increased incidence of emotional disturbances and other psychopathology. We undertook this research to study the prevalence and severity of depression and anxiety as well as understand body image disturbances and self-esteem of the women of PCOS. We studied the relationship of depressive symptoms with self-esteem and body image disturbances. METHOD: A total of 105 patients diagnosed as PCOS were recruited from gynecology OPD after informed consent and ethics approval. A proforma along with Beck's Depression Inventory, Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Body Image Concern Inventory and Rosenberg' s Self-Esteem Scale were administered to patients for further assessment. RESULTS: In total, 54 (51.43%) patients of PCOS had depression on BDI, 12( 11.43%) patients had body image disturbances an d 23 (21.90%) patients had a low self-esteem. A total of 21 patients( 20%) had mild and moderate depression while 5% had severe depression. Majority 53 (50.48%) of our patients had mild anxiety whereas severe to extreme anxiety was seen in about 31% of patients. Body image disturbances were seen in only 12(11.43%) patients and low self-esteem was present in 23 patients. No statistically significant correlation of depression was seen with body image or self-esteem. CONCLUSIONS: The results of this study indicate that there is a high prevalence of depression and anxiety in patients of PCOS than body image concerns and low self-esteem. Prognosis for patients would improve by liaison between gynecologist and psychiatrist.

Vaginal Dysbiotic Microbiome in Women With No Symptoms of Genital Infections.

The vaginal microbiome plays a critical role in determining the progression of female genital tract infections; however, little is known about the vaginal microbiota of Indian women. We aimed to investigate the vaginal microbial architecture of women with asymptomatic bacterial vaginosis (BV) (n=20) and normal microbiota (n=19). Microbial diversity was analyzed in vaginal swabs from regularly menstruating women (18-45yrs) by 16S rRNA V3-V4 amplicon (MiSeq Illumina) sequencing. Rarefaction analysis showed a higher number of species in normal flora compared to BV. Alpha diversity as measured by Pielou's evenness revealed microbial diversity was significantly greater in BV samples than normal microbiota (p= 0.0165). Beta diversity comparison using UniFrac metrics indicated distinct microbial communities clustering between normal and BV flora. Firmicutes were the major phyla observed in vaginal specimens of normal microbiota whereas Actinobacteria, Fusobacteria, Bacteroidetes were significantly abundant in BV samples. Notably, the relative abundance of Lactobacillus was significantly high in normal microbiota. Conversely Gardnerella, Sneathia, Prevotella, Atopobium, Ureaplasma, Dialister significantly dominated dysbiotic microbiota. Relative frequency of Lactobacillus decreased significantly in BV (6%) as compared to normal microbiota (35.2%). L. fermentum, L. gasseri, L. iners, L. jensenii, L. mucosae, L. ruminis, L. salivarius, L. coleohominis was more exclusively present in normal microbiota. L. iners was detected from both the groups with a relative frequency of 50.4% and 17.2% in normal and BV microbiota respectively. Lefse analysis indicated Atopobium vaginae, Sneathia amnii, Mycoplasma hominis Prevotella disiens in the vaginal microbiota as a biomarker for dysbiosis and L. jensenii as a biomarker of a healthy microbiota. Firmicutes were negatively correlated to Tenericutes, Actinobacteria, Bacteroidetes, and Fusobacteria. Proteobacteria positively correlated to Tenericutes, and Bacteroidetes were shown to be positively correlated to Fusobacteria. Predicted functional analysis indicated differences in the functional profiles between BV and normal microbiota. Normal microbiota utilized pathways essential for phosphatidylglycerol biosynthesis I & II, peptidoglycan biosynthesis, geranylgeranyl diphosphate biosynthesis I, mevalonate pathway, CoA biosynthesis pathway I and pyrimidine nucleotide salvage; whereas BV bacteria had characteristic aromatic amino acid biosynthesis, pentose phosphate pathway, carbohydrate degradation. In conclusion, women with asymptomatic BV have vaginal microbiota significantly different than women with normal microbiota. Furthermore, the study provides insights into the vaginal microbial structure of Indian women that will enable us to explore the prospective candidates for restoring the vaginal microbiota.

Cross sectional analysis of vaginal Lactobacillus in asymptomatic women of reproductive age in Mumbai, India.

INTRODUCTION: Lactobacillus dominated vaginal microenvironment is associated with lower risk of genital infections. Numerous studies have reported geographic and ethnic variations in vaginal microbiome structure between healthy individuals from different race and ethnicity. India has a great diversity, so it is intriguing to find out if such divergences exist in vaginal lactobacilli. The present study aimed to investigate predominant Lactobacillus species in vaginas of healthy Indian women and screen isolates for lactic acid and H2O2 production. METHODOLOGY: 203 premenopausal women asymptomatic for any vaginal complaints were recruited. The lactobacilli isolates on MRS agar were identified by Multiplex-PCR and 16sRNA gene sequencing. RAPD was used to differentiate strains of same species. H2O2 and lactic acid was evaluated on TMB-HRP MRS agar and BCP-MRS agar respectively. RESULTS: Lactobacilli were recovered from 107/109 (98.2%) women with normal microflora. L. iners 64.7% (68), L. crispatus 26.7% (28), L. reuteri 21.9% (23), L. jensenii 16.2% (17) and L. gasseri 15.2% (16) were the most frequently occurring vaginal lactobacilli in normal women. The vaginal microflora was dominated by either by a single (80%, n = 84) or a combination (20%, n = 21) of Lactobacillus species. Though most frequently identified, L. iners, coexisted only with other Lactobacillus species. All isolates were acid producers but H2O2 was produced by 94.2% isolates. CONCLUSIONS: Our study reports prevalent vaginal lactobacilli which could be explored as probiotics. Presence of heterogeneous Lactobacillus population highlights the cumulative effects of different lactobacilli maintaining vaginal health. Contrasting observations about L. iners reiterates its puzzling role in vaginal immunity, advocating further research.

Trends in cesarean delivery: rate and indications.

OBJECTIVES: To compare the cesarean delivery rates over the last decade and to examine the indications contributing to changed trends, if any. METHODS: To compare the rate and indications of cesarean delivery over the last decade, the data were collected in a retrospective manner from all the deliveries that occurred between January 1 and December 31 in 2001, 2006, and 2011, in the department of obstetrics and gynecology, Seth G.S. Medical College and K.E.M. Hospital, a large tertiary care municipal hospital in Western India. A cohort of 20853 delivered women was studied. The rates and indications of primary and repeat cesarean sections were analyzed among the live births to estimate the relative contribution of each indication to the overall increase in rate. RESULTS: The cesarean delivery rate increased from 171.70 to 289.30 per 1,000 live births, with an increase in primary cesarean delivery rate from 118.53 (69.03 %) in 2001 to 210.09 (72.62 %) in 2011 per 1,000 live births. Fetal distress, arrest of descent, multiple gestations, and fetal indications contributed to this increase. CONCLUSIONS: There is a significant increase in the total cesarean rate with primary cesarean accounting for most of the increase.

Non-puerperal incomplete lateral uterine inversion with submucous leiomyoma: a case report.

A perimenopausal, multiparous woman presented with prolapse. Clinically, there was a doubt between prolapsed submucous leiomyoma and uterine inversion. Laparoscopy showed an unusual pattern of uterine inversion restricted to the left cornual region with a submucous leiomyoma. A vaginal hysterectomy with due considerations for alterations of anatomical relationships minimized operative morbidity.

Pregnancy outcome after operative correction of puerperal uterine inversion.

Uterine inversion is an uncommon but life-threatening obstetric emergency. A review of the approaches to correct uterine inversion is presented. In cases where time has elapsed between delivery and presentation, the inversion ring may have become too tight to allow manual reposition of the fundus. In such cases, it has to be divided by a vertical incision. In subsequent pregnancy, antenatal care should include placental localization and planning for an elective Caesarean Section. The outcome of future pregnancies may be complicated by placenta accreta and massive haemorrhage.